2013 quality report

Nearly 90 percent of the rehabilitation patients

in our skilled nursing centers are discharged

home, with the majority of the others deciding

that they need the 24/7 care of long-term

skilled nursing services.

We Are HCR ManorCare 4

Getting People Home 5

Reducing Hospital Readmissions 7

Our Professional Staff 9

Your Best Way Home 11

Partnerships to Improve the Transition of Care 13

Hospice and Home Health Care 16

Memory Care 20

Quality Care from a Quality Workforce 24

Page

Inside

“ I have been to other rehab centers in the

area, and what makes ManorCare Health

Services–Naperville different is the people

who work here. I have family members in

the medical field, and they recommended

that I choose ManorCare this time.

The people who work here are the best.

The Naperville location is almost all rehab,

so it doesn’t feel like a ‘nursing home.’

I have received the best care here that

I possibly could. I would recommend

it to anyone who is looking to receive

outstanding care.”

Larry – ManorCare Health Services–Naperville

Experiencemakes a difference

2 Experience Makes a Difference

6

7

12

3

4

316

7

8

2

2

2

2

1

1

1

3

3

78

3652

4

55

40

16

10323

SkILLed NuRSING ANd ASSISTed LIvING CeNTeRS

HOMe HeALTH CARe ANd HOSPICe AGeNCIeS

1

10 4

4

241

3

9

2

5

12

69

617

4

19

5

2

232

5

1

3Experience Makes a Difference

We are HCR ManorCaren Quality caring provided by 58,000 employees through

more than 500 locations in 32 states

n One of the largest providers of post-hospital skilled nursing and rehabilitation through more than 280 centers, most of which provide care under the respected names of Heartland and ManorCare Health Services

n With rehabilitation outcomes for Medicare patients comparable to and often exceeding those of independent rehabilitation facilities

n The third largest U.S. provider of hospice care in over 100 markets under the Heartland name

n A leading U.S. provider of home heath care under the Heartland name

n A leading provider of Alzheimer’s/dementia care through 54 Arden Courts memory care communities and in many of our skilled nursing centers

n Rehabilitation also provided in more than 50 outpatient therapy clinics, primarily under the Heartland name

Of HCR ManorCare’s more than 280 skilled nursing and rehabilitation centers, 85 percent are either at the 4 or 5 level for the quality measures of the Five-Star Quality Rating System, compared with a national average of 58 percent.


We focus on getting people home because that’s what most people desire. Nearly 90 percent of our patients have come directly from the hospital, and all have come because they are not quite ready to get on with their lives. They have experienced a disabling illness, surgery or injury, and the hospital has treated and stabilized the condition. Now they have chosen our centers to receive the rehabilitation and other services they need to complete their recovery and return home.

As the clinical complexity of post-acute care patients increases in the United States, HCR ManorCare has embraced a new role as a care provider capable of treating patients with hospital-level acuity, and offering patients a combination of clinical excellence and rehabilitation sophistication. On average, the patient population at our centers is more clinically complex than the patients treated in other skilled nursing facilities across the United States. This is particularly true among the percentage of patients receiving rehabilitative care. The average of HCR ManorCare patients requiring rehabilitation in 2012 was 39 percent, 13 percentage points higher than the average of providers as a whole. In terms of medical complexity, our centers also care for a greater

Getting People Homepercentage of patients requiring IV therapy, chemotherapy and dialysis care, among others, as can be seen from the charts on page 6. Today, 89 percent of our rehab patients are discharged home, with the majority of the others deciding that they no longer can function well on their own and need the 24/7 services offered through long-term care. The average length of stay for our post-acute patients is 34 days, and over 65 percent are discharged in less than 40 days.

Annually, we make considerable investment in an increased number and higher skill level of professional staff, advanced therapeutic techniques, state-of-the-art rehabilitation space and equipment, specialized evaluations and testing to measure progress, and patient and family training to prepare for the transition home. This investment has also included amenities valued by a younger patient population that has different needs from a nursing center’s traditional long-term residents. We are improving the probability of a successful outcome and increasing the percentage of patients returning home with an equal or higher level of functioning.


Average Daily Percent of Patients Receiving Chemotherapy

0.4

0.3

0.4

0.3

0

0.2

0.3

0.1

0.4

0.5

0.6

Perc

ent 2008 2009 2010 2011 2012

0.3

0.4

0.5

0.5

0.4

0.3

HCRMC Other

On any given day in 2012, HCR ManorCare’s skilled nursing and rehabilitation centers provided rehabilitation to about 50 percent more patients on average than what was provided on average by other skilled nursing centers nationwide.

Average Daily Percent of Rehabilitation Patients

39.3

23.8

0

10

20

30

50

Perc

ent

40

41.1

2008 2009 2010 2011 2012

22.2

40.3

39.0

39.2

24.4

25.2

25.9

HCRMC Others

Average Daily Percent of Patients Receiving Dialysis

2.6

1.9

2.8

1.7

0

1

2

3

Perc

ent

4

2008 2009 2010 2011 2012

1.7

3.1 3.2

2.9

1.8 1.

9

HCRMC Other

Average Daily Percent of Patients Receiving I.V. Therapy

1.7

4.7

2.0

0

1

2

3

5

Perc

ent

4 3.9

2008 2009 2010 2011 2012

1.8

4.5

4.3

4.0

2.0

1.6

HCRMC Others

Patients at our skilled nursing and rehabilitation centers generally require a higher level of clinical care. The average percentage of our patients receiving I.V. therapy, dialysis and chemotherapy, for example, was significantly higher in 2012 than that of other centers.

Experience Makes a Difference

With more than 35 years of experience in the industry, we understand what it takes to help our patients reach their rehabilitation goals and return home. In 2012, more than 160,000 patients chose HCR ManorCare for their post-hospital care, including:

•46,521orthopedicpatients

•5,446strokeandneurologicpatients

•25,598cardiacpatients

•6,937oncologypatients

•13,425pulmonarypatients

Recovering from a hospital stay can be daunting. Our experience makes a difference in how successfully and how quickly patients get back to their lives.

Source: TSI Trends

Source: TSI Trends


Reducing Hospital Readmissions Successful Transition of Care

Because discharged patients are leaving the hospital much sooner than in the past, they are more likely to be readmitted to the hospital due to lingering or new medical complications. The cost of these readmissions is prohibitive to the health care system and a target of government agencies to remove cost from the system. Just as important, once patients are released from the hospital, they don’t want to go back. HCR ManorCare is working closely with its hospital referral sources to help ensure there is a smooth transition from hospital to our centers so that when patients leave the hospital, they do not return.

In our effort to better understand the dynamics of hospital readmissions, we have created a dashboard to monitor the percentage of patients with unplanned rehospitalizations within 30 days of admission. The rehospitalization dashboard provides the ability to drill down to patients admitted from specific hospitals, as well as identify the level of medical practitioner sending them back to the hospital. At the suggestion of HCR ManorCare’s Independent Advisory Committee on Quality, the percentage of patients with readmissions are also examined in three time segments within the 30-day window – within 48 hours, 3-7 days and 8-30 days. The time between admission and discharge back to the hospital facilitates discussions during joint transition of care meetings.

Transition of Care Benefits from Open CommunicationCare transitions require open communication across care settings and collaboration among professional roles and concerned parties – hospital to post-hospital care provider, nursing assistant to nurse, nurse to doctor, and all caregivers to the patient and his or her family. This should be a patient-centered process that begins by listening to the patient’s expectations, preferences and ability to be engaged in self-management activities. Self-management includes patients knowing when and why they take certain medications, possible side effects and/or knowing enough about their condition to recognize the early warning signs to contact the physician. Such collaboration reduces unnecessary, redundant testing and potential medication discrepancies; clarifies medical complexities; and pinpoints predictive risk factors.

A center’s interdisciplinary team meets periodically with recently admitted post-hospital patients to discuss their progress toward their discharge-readiness goals and assist with identifying further patient/family education needs to manage patient care post discharge. To this point, it is important to empower the patient by validating the ability to demonstrate the skill or knowledge and have questions answered. Post-discharge follow-up to answer questions, ensure physician appointments are kept and make sure support resources are available further reduce the threat of unnecessary rehospitalizations.

Communication is especially critical to decreasing rehospitalizations within the first 30 days of a patient’s stay in the post-hospital care setting. HCR ManorCare’s Transition of Care form helps improve communication between the hospital and the post-hospital center when

a patient is discharged. Evidence-based medicine indicates that the communication of specific and focused patient information can reduce those “bounce-backs” which occur in the first 24 to 48 hours.

Additionally, we have implemented a series of educational programs to train nurses and nursing assistants in the early warning signs for care conditions that have been identified as unnecessary reasons for rehospitalizations. This educational initiative is designed for everyday use and instructs the clinical teams in providing appropriate interventions for these specific care conditions. Missed communications are a primary cause of rehospitalizations that occur between day 8 and day 30 after discharge. Our educational initiatives have reduced rehospitalizations in this time period by as much as 40 percent.


Joint Transition of Care CommitteesHCR ManorCare has created Joint Transition of Care Committees with key hospital systems. The committees comprise operational, medical, clinical and business development leaders from HCR ManorCare and the participating hospital system. The joint initiative provides an important point of accountability for ensuring both quality of care and quality of life throughout the transitions of care. The objectives of the committee are to:• Improvethequalityofpatienttransitionsacrossthe continuum of care.• Reducethepreventableandunnecessaryrehospitalization of patients.• Enhancepatientsatisfaction.

electronic Innovation and IntegrationEarly identification, evaluation, documentation and communication of patients who have a change in status are reducing rehospitalizations and the associated emotional and physical complications. Nursing assistants at our centers access conveniently located electronic kiosks to record changes in patient conditions such as mental status, communication skills, participation in activities, ability to perform activities of daily living, fatigue and changes in skin color or condition. This information sends an alert to licensed staff, enabling our clinical team to identify issues early and communicate change in condition to physicians to initiate interventions to avoid unnecessary trips to the hospital.

This is just one example of our focus on bringing electronic systems innovation to our clinical delivery. Other enhancements include:• Physicianaccesstoelectronichealthrecords.• Nursepractitionerelectronicnotepads.• PointClickCareelectronicmedicalrecordsystem.•Therapymanagementsystems.

At an average of 18 percent, our skilled nursing

and rehabilitation centers’ rehospitalization

rate is lower than the national average, with

many of our centers achieving rates lower than

10 percent.

Caring for Longer-Stay ResidentsWhile short-stay patients in need of intensive rehabilitation are an increasing percentage of those we care for, we also continue to care for a medically complex, functionally limited and/or cognitively impaired longer-stay population. Many enter a nursing center only as their care needs go beyond their ability to stay in their homes. Others enter because their frailty and need for around-the-clock, comprehensive care can best be met in a professional care setting. Community-based services are enabling people to stay longer in their homes or assisted living residences, and this means by the time they do come to our skilled nursing centers, they are in need of more intensive care than this population required 10 to 15 years ago. Nearly half are taking nine or more medications.

These residents come from the hospital, home and other community residences and need assistance in performing activities of daily living (ADLs), such as walking, eating and bathing. Much like short-term patients, they receive physical, occupational and speech therapies to keep their functional level at as high a level as possible. They may also require pain management, medication management, wound care, and counseling and social services. Some short-term patients may become long-term residents. After receiving the rehabilitation and other care required, it’s often determined that the patient is not going to progress to the point where he or she can return to the community. He or she needs a level of care that cannot be safely provided at home.


Experience Makes a Difference

To address changes in patient acuity, we have made considerable investments in professional staff to meet the requirements of patients who have more complex needs than a traditional nursing center’s long-term residents. The care and services given to a higher-acuity patient population necessitate employing a greater number of specialized professionals to efficiently guide progress, manage discharge planning and reduce the probability of the patient going back to a hospital setting.

Recognizing this shift in patient acuity, we have added nurse practitioners to the professional care teams at centers across the country. While we have employed nurse practitioners in our centers for more than a dozen years, we have determined that utilizing nurse practitioners with a higher level of medical expertise through a center-based medical practice model would enable us to provide

Our Professional Staffhigher quality care to more complex patients. The center-based nurse practitioner works with the medical director and/or designated attending physicians to establish a medical practice within the center through an independent but collaborative relationship.

Our centers targeted for this program include those serving a patient population with at least 40 percent short-stay residents (lengths of stay less than 28 days) and discharge to our skilled center immediately following hospitalization. Further, centers accepting higher volumes of patients with shorter average hospital lengths of stay (3-6 days) were chosen for the program to more effectively meet the needs of patients requiring higher levels of care and enable us to accept more challenging patients.

The Role of the Nurse Practitioner Nurse practitioners with an established medical practice provide comprehensive evaluations of new admissions either prior to or following the initial assessment by the patient’s attending physician, which generally includes an examination of the patient’s medical history and physical condition. To foster improved processes at our centers, we have established thresholds for medical practice nurse practitioners to ensure timely assessment of new admissions. At least 70 percent of new admissions must be seen within 48 hours of admission, and further follow-up must be completed on days 3, 10 and 28 of the patient’s stay at our center. Additionally, if a patient has a primary diagnosis on admission of

“I had so much pain every day that I found I was missing out on the important things in my life and the lives of my family. I found that a bilateral knee replacement was the best option for my specific case and chose ManorCare Health Services–Akron for my post-surgery care and rehabilitation. The therapy I received was excellent; the staff was professional and eager to help me walk again. After a one-month stay, I passed my home assessment test with flying colors. I was discharged home and did not use my walker or a cane. I have regained my independence, with little or no pain. I have a better quality of life because I trusted ManorCare Health Services–Akron, and it took a month, not a year!”

Beverley – ManorCare Health Services – Akron


congestive heart failure, acute myocardial infarction or pneumonia, he or she is seen daily for seven days and then a minimum of weekly thereafter for the first 30 days.

Measuring Success of the Center-Based Nurse Practitioner ProgramAs a preventative intervention program, success can be difficult to measure. But we have found that centers participating in our Center-Based Medical Practice Nurse Practitioner Program have improved medical, clinical and administrative results and significantly reduced rates for readmission to the hospital setting. High-acuity centers with medical practice nurse practitioners are successfully managing complex cases by reducing preventable and unnecessary readmissions to the hospital and avoiding a gap in the continuum of medical care provided when a patient transitions from the hospital to the post-hospital care setting. The Center-Based Medical Practice Nurse Practitioner Program has been particularly instrumental in reducing rehospitalization rates within the critical three- to seven-day admission window by 30 to 40 percent.

Nurse Practitioners and Advanced Disease ManagementHeartland Care Partners is a provider of short- and long-term health care with a particular emphasis on effectively treating medically complex patients. Oftentimes, patients with progressive illnesses and persistent symptoms can benefit from a higher level of consultation, management and involvement than they are receiving in their current setting. Heartland Advanced Disease Management is a program under the direction of Heartland Care Partners to provide patients with advanced disease and pain management when they are chronically ill but not quite ready or appropriate for hospice or dedicated end-of-life services. This initiative not only involves skilled nursing centers, but home health care and hospice agencies, as well.

Referrals primarily come from patients’ attending physicians, oncologists and hospitalists. Heartland Care Partners staff processes the referrals and matches patients with nurse practitioners. They, in turn, provide consultation services to patients, physicians and families regarding recommendations for pain/symptom management and complex health care needs related to diseases such as cancer, heart disease, pulmonary disease, Alzheimer’s disease and disease combinations.

This program fills a critical gap in the health care continuum and helps to improve transitions of care by addressing chronic disease processes, uncontrolled pain and end-of-life decision making.

JudithManorCare Nursing and Rehabilitation Center–Naples

“After asking for recommendations on

facilities that have exceptional post-hospital

care, I decided on ManorCare Nursing and

Rehabilitation Center–Naples. Upon arrival,

I was greeted by the administrator and

escorted to a nice room with a large window

overlooking a lovely courtyard. I was very sick

and required a great deal of care, which was

promptly attended to by the nursing staff.

The therapy department was everything I had

heard and more. You just wouldn’t believe

how the therapists were always smiling and so

encouraging. I am now going home and feel

confident that I will be able to care for myself

independently. I will miss the staff greatly, as

they have become like a family to me. When

you find yourself in need of post-hospital care,

I hope you make the same decision as I did –

ManorCare Naples.”


HCR ManorCare’s companywide average shows progress in rehabilitation Mobility skills that is significantly greater than results from U.S. inpatient rehabilitation facilities (IRFs).

Improvement in Mobility from Admission to Discharge for Medicare Patients (2012)

2.27

2.12

1.90

1.69 1.

761.

60

1.94

1.87

1

1.50

2.00

2.50

3.00

Inde

xed

Scor

e Orthopedic Cardiac Pulmonary Stroke

HCRMC IRF

HCR ManorCare’s companywide average shows progress in rehabilitation Self-Care skills that is significantly greater than results from U.S. inpatient rehabilitation facilities (IRFs).

1.90

1.68

1.59

1.38

1.59

1.41

1.67

1.53

1.00

1.50

Inde

xed

Scor

e

2.00

Orthopedic Cardiac Pulmonary Stroke

HCRMC IRF

Improvement in Self-Care from Admission to Discharge for Medicare Patients (2012)

1.25

2.25

1.75

HCR ManorCare is meeting the needs of patients who are discharged from hospitals and need rehabilitation to go home and resume their lives. We have raised the bar for aggressive, short-term, expert and outcomes-focused rehabilitation – with an impressive track record of success in achieving necessary results for our patients and their families. We believe to assure effective medical care and rehabilitation – and continuously improve – providers must measure and compare outcomes to benchmarks and targets. Further, we believe it is vital for patients and their families, as well as those who refer patients, to examine evidence of a post-acute care provider’s success before deciding whom to trust.

We measure patient outcomes to drive our ongoing commitment to improve clinical effectiveness, to provide objective evidence of our success, and to give patients and their families the data they need in choosing the best provider to achieve their care goals and a return to their lives.

In 2012, an average of about

6,000 physical, occupational

and speech full- and part-time

therapists provided rehab to

our patients who were eligible.

Your Best Way Home is Through Our Doors Our Outcomes Prove it


MarvinManorCare Health Services–kenosha “I chose to rehabilitate at ManorCare Health Services–Kenosha when I heard great things about the therapy department. Before I returned home after cardiac surgery, I needed some physical and occupational therapy, and after just a few short weeks, I felt confident about returning home to live independently. I am better physically, but mentally, too. The staff at ManorCare took good care of me, the food was good, and I feel prepared to go home. I would definitely recommend ManorCare–Kenosha to anyone who needs rehabilitation after a hospital stay.”

From admission to discharge, HCR ManorCare’s companywide average shows our rehabilitation patients make a dramatic improvement in their ability to walk.

3226

2

5430

5

3128

4

4927

3

0

50

100

150

350

Feet

250

300

200

HipFracture

HipReplacement

KneeReplacement

MultipleFractures

Admission Discharge

Average Walking Distance Improvement of Medicare Orthopedic Patients (2012)

Nearly 90 percent of our rehabilitation patients discharged to the community report they are prepared to manage their care at home, compared to about 3 percent who are prepared when they’re first admitted from the hospital.

0

20

40

60

10090

70

50

30

10

Perc

ent

80

3.1

Upon Admission

Upon Discharge

88.2

Percentage of Patients Able to Manage Their Care Needs (2012)

“Much thought and research went into finding an excellent rehabilitation center to help me recover after a hospital stay. My wife did research on the Internet and toured every community in the Holland area before choosing this center. I am thrilled with the care I received at Heartland of Holland. If it wasn’t for the staff and how well they interacted and cared for me, I would never have accomplished what I did. My rehabilitation team was the best. Their specialized programs and persistence with me really paid off. I feel stronger today than I did even before I became ill. Thank you all at Heartland of Holland. I will recommend your service to everyone.”david – Heartland of Holland


Innovation in Post-Acute Care: Bed Reservation AgreementPartnership with John Muir Hospital

HCR ManorCare has contracted with John Muir Hospital under a bed lease agreement to provide 25 beds exclusively for John Muir patients at one of the company’s skilled nursing and rehabilitation centers in the San Francisco area. The hospital has physicians at this center seven days a week attending to patients in these designated beds. The hospital has provided lab services and purchased telemetry equipment for physicians’ use at the center so patients do not have to be readmitted to the hospital for simple tests and cardiac monitoring. In addition, a Quality Review Committee comprises members from both companies, including physicians, inpatient case managers, medical home case managers, and clinical operations and administrative staff. The committee is a forum for information on quality measures, rehospitalization, customer service, outcomes and any regulatory updates. Informal discussions occur regularly. We work to decrease average length of stay in the hospital by being able to take patients earlier, decrease rehospitalization, maximize efficient use of shared resources and streamline the transition of patients as they pass through different levels of the care continuum.

Partnerships to Improve the Transition of CareHCR ManorCare has joined with referral sources, health care insurers and others in the health care field to find ways to improve the quality of health care and reduce the number of patients being readmitted to the hospital. Here are three examples of these partnerships.

Innovation in Post-Acute Care: Bundled Payment demonstrationPartnership with Optum, a leading health services company

The Bundled Payments initiative offered through the Center for Medicare & Medicaid Innovation (CMMI) will link payments for multiple services patients receive during an episode of care. Optum has partnered exclusively with HCR ManorCare to participate in this initiative for a three-year period beginning in June 2013. Optum has extensive experience in creating preventive care models that focus on treating in place to avoid unnecessary hospital admissions and readmissions. This demonstration program will focus on developing new clinical models aimed at increasing the efficiency and collaboration of care across care settings, with a goal of improving care and patient satisfaction while reducing hospital readmissions and cost.

Innovation in Post-Acute Care: Joint Construction of Skilled Nursing CenterPartnership with ProMedica

HCR ManorCare is partnering with ProMedica in northwest Ohio to develop a multimillion dollar skilled nursing and rehabilitation center on a ProMedica hospital campus. It will provide medically complex and intensive rehabilitation services for short-term patients transitioning from hospital to home, in addition to 24-hour skilled nursing care. A key provision of the collaboration is forming a quality committee with clinical staff from both HCR ManorCare and ProMedica to focus on reducing preventable and unnecessary rehospitalizations and improving both patient care and satisfaction. The committee also will serve as a liaison for patients and their families in ensuring an orderly transition between a hospital and skilled nursing setting. As a preferred provider for skilled nursing and rehabilitation services for ProMedica, HCR will ensure that for patients electing to receive these services there are dedicated beds at its nursing and rehabilitation centers to meet the demand of ProMedica patients.

Rendering of proposed new skilled nursing and rehabilitation center on ProMedica campus.


Over the past three years, we invested

more than $100 million annually in new

construction, renovation and expansion

of existing facilities; new equipment; and

information technology. Three new skilled

nursing and rehabilitation centers were

opened, and two are under construction.

Thirty-one expansions were completed,

and 13 are under way to add short-term

stay beds and enhance rehab therapy

areas. Nearly 900 renovations, each

at a cost of more than $30,000, were

completed.

Collecting and using patient satisfaction survey data is an important part of our process for ensuring that patients feel that they have received the care they expected. HCR ManorCare uses an independent organization to collect and manage the data collection process. We are proud to report that results from these surveys show high levels of satisfaction. In 2012, over 25,000 discharged patients from our skilled nursing and rehabilitation centers returned surveys, which has helped us create a good gauge of patient satisfaction.

Achieving high levels of customer satisfaction begins with training our employees. We have developed a training program called Patient-

91% of patients rated the

quality of the rehabilitation

therapy they received as

“Excellent” or “Good.”

92% of patients rated

the respect shown them

by therapists and nurses as


91% of patients reported being

satisfied with the encouragement

their therapist provided to help

them meet their individual

rehabilitation goals.

Quality Care Reflected in Satisfaction SurveysFocused Customer Service. This program helps employees understand how service is perceived by patients and family members. The program focuses on improving professionalism in three areas -- Appearance, Attitude and Action. New employees complete Patient-Focused Customer Service during general orientation. In addition, the program is taught annually to all current employees to reinforce the importance of providing excellent customer service each day. Also important in achieving customer satisfaction is educating our patients and families about the normal aging process. We use a wide variety of communication materials to enhance their understanding of this process.


On average in 2012, the Medicare and managed care patients in our skilled nursing and rehabilitation centers returned to the community in less than 37 days.

Insu

ranc

e/M

anag

ed C

are

25.3

Med

icar

e

36.9

Hosp

ice

68.692.9

Priv

ate

Pay

Vete

rans

Adm

inis

trat

ion

98.9M

edic

aid

265.2

0

50

100

150

200

300

Day

s

250

Average Length of Stay in Days

Almost all of our skilled nursing and rehabilitation center Medicare patients received at least one form of rehabilitation therapy in 2012.

Percent of Medicare Patients Receiving Therapy

0

20

40

60

80

100

Perc

ent Any

TherapyPhysicalTherapy

OccupationalTherapy

SpeechTherapy

97.7 96.1 95.7

36.1

The vast majority of our skilled nursing and rehabilitation center patients came to us from the hospital in 2012.

Residence Prior to Admission to HCR ManorCare

Acute Care Hospital 88.5% Nursing Home 4.0% Home 3.5% Other 4.0%

HCR ManorCare has created an Independent Advisory Committee on Quality to provide advice and recommendations to the company’s Board of Directors on ways to measure, maintain and improve quality of care for HCR ManorCare patients and residents. The distinguished three-person panel is composed of Vincent Mor, Ph.D., Professor of Medical Science in the Department of Health Services, Policy & Practice at the Warren Alpert Medical School, Brown University; Robyn Stone, Dr.P.H., Executive Director of the Institute for the Future of Aging Services and Senior Vice President of Research for LeadingAge; and Gail Wilensky, Ph.D., Economist and Senior Fellow at Project HOPE.

The Independent Advisory Committee on Quality met four times in 2012 focusing on initiatives to manage care transitions, ongoing quality assurance and performance improvement processes, and advances in electronic medical record.

HCR ManorCare Independent Advisory Committee on Quality


HEARTLAND MISSIONWe believe that our mission is to enrich lives. That begins

with every life we encounter – our employees, our patients

and those who love and care for them, the communities in

which we operate, our stakeholders and those who are yet to

become our customers.

HEARTLAND PROMISESWe promise to care for the mind, body and spirit in a way that is comforting and compassionate.

We provide care that not only addresses physical concerns but also the psychosocial and spiritual needs of patients. The goal is to provide care in a way that offers a blanket of comforting and compassionate support for the whole person and his or her family, no matter what the issue.

We promise to be the difference in our customers’ day, working to make every connection a personal one, and creating memorable moments that define their Heartland experience.

We work to help create special moments for our customers that they will always remember, moments that make them feel warm, cherished and valued.

We promise to discover what is important to our customers, respect their choices and customize our service specifically to their needs.

We work to provide our patients with the support they need wherever they are in their health care journey. We ask them questions to find out exactly what they want and need and then help them get it. It is our patients’ choices that matter most, not ours.

We promise to be leaders in care delivery, corporate responsibility and community action.

First, we want to be leaders in care delivery. Our goal is for every employee to model behavior that is committed to quality care and service. No matter what the employee’s job, it is critical to the services we provide.

Second, each employee needs to do his or her part to keep our company healthy so that we have the tools and systems necessary to do the important work that we do for our patients and families.

Third, we strive to be part of the fabric of the communities in which we operate and serve. We will help by providing education and information, partnering with community resources and taking actions in the community that benefit more than our patients.


Hospice and Home Health CareHospice ServicesHospice isn’t a place. It’s a philosophy of care, and we call our hospice mission enriching life. Heartland Hospice is dedicated to providing patients with care wherever they consider home. Whether care is desired in the home a patient has lived in for years, a skilled nursing center or an assisted living facility, caregiving is tailored to fit the patient’s and family’s unique needs.

Heartland’s caregivers enrich patients’ lives and provide support by developing individualized care plans, setting goals, encouraging personal choices, working together in caregiving decisions and supporting meaningful experiences. Our caregivers help manage pain and symptoms, enabling patients to live life as fully and comfortably as possible. Social workers and spiritual counselors create a comforting environment in which patients and families are able to share their thoughts, hopes and concerns. And special bereavement programs provide emotional support to patients and families who need help coping.

Our hospice services integrate holistic principles with palliative disease management, expert pain and symptom control, family education and psychospiritual support for end-of-life care. We also provide the education, counseling and other resources that can help with emotional needs. Care is culturally sensitive, respecting the traditions and heritage that are important to patients and their family members.

Heartland Hospice is proud to be part of the We Honor Veterans program launched by the National Hospice and Palliative Care Organization in collaboration with the Department of Veterans Affairs to help improve the care veterans receive from hospice and palliative care providers. In 2013, four Heartland Hospice agencies achieved the highest level of recognition in the program and were among a total of only 67 agency locations across the country so recognized. Heartland is a provider whose employees are trained to care specifically for veterans.

“ My mother’s hospice team gave her care and

compassion. It meant so much knowing she was in

their care, as I was so far away. Her hospice nurse

was always available by phone. Her insight and

kindness helped me through a difficult time.”

– daughter of a Heartland Hospice patient in Iowa

“ All I can say is that everyone was awesome. You all

will be highly recommended by me. Dad’s nurse was

fantastic with him, made his last days comfortable.

Your team was very helpful and always there, and

they cared, and that’s important. Thank you for

your services.”

– daughter of a Heartland Hospice patient

in Wisconsin

“ I cannot begin to express my grateful feelings

for all of the nurses and members of Heartland.

For both the physical and emotional aspects,

Heartland prepared both my mother and me

during this time for what to expect and was an

immeasurable aid to me.”

– Son of a Heartland Hospice patient in Pennsylvania


Home Health Care ServicesHeartland Home Health Care provides advanced medical care combined with a compassionate touch, in an environment where patients are most comfortable – their own home. Heartland’s care and services are coordinated and supervised by a registered nurse or therapist, and are focused on enriching patients’ lives by helping them restore their independence and once again feel as if they are in control. The Heartland care team:

n Provides comprehensive skilled nursing care, therapy services and I.V. therapy.

n Educates patients, families and caregivers on disease self-management and newly diagnosed diseases such as diabetes, Alzheimer’s disease, heart disease and chronic obstructive pulmonary disease. We have developed a library of comprehensive medical and rehabilitation management programs to serve our patients better.

n Assists in medication management including assessing new medication, dosage, changes in frequency and interactions with other medications.

n Performs therapy services to help patients recovering after surgery, illness or injury.

If a patient is experiencing an illness, hospitalization or surgery and requires recovery and healing, or if he or she is facing a new health care diagnosis requiring a change in daily lifestyle, home health care is often a desirable solution. Heartland provides support to patients and family members by identifying goals and potential obstacles, and helping patients recover, understand and identify symptoms, manage medication, and learn to deal with anxiety, fear or other feelings that come with illness.

Our home health care rehospitalizations in 2012 were well below the national average.

Percent of Home Health Care Patients Who Returned to the Hospital

0

10

20

30

Perc

ent Heartland Industry

Average

25

15

5

1417

“ This company seems to attract the most skilled and

compassionate people to serve in their positions.”

Heartland Home Health Care patient in virginia

“ Everyone I saw was efficient and professional as well

as kind and considerate. I couldn’t have asked for

better care in every respect. They were all great.”

Heartland Home Health Care patient in California

“ I was very pleased with the care I received. I found

my nurse to be very knowledgeable and extremely

caring. I enjoyed her visits very much.”

Heartland Home Health Care patient in Michigan


I.v. Care Heartland employs specially trained pharmacists and nurses who work with the patient’s physician to oversee the administration of I.V. medications and tube feeding at home for conditions such as infections, cancer, multiple sclerosis and diseases of the digestive tract. Our home I.V. pharmacies prepare medications, provide administration supplies and coordinate care with the patient’s physician and nursing provider. The goal is to enable patients to be in their homes with I.V. care that is safe and easy. In 2013, Heartland I.V. Care was awarded 41 Competitive Bid Areas as part of Medicare’s DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics and Supplies) Competitive Bidding program administered by the Centers for Medicare & Medicaid Services. Only providers awarded contracts through the competitive bidding process will be able to serve patients once the contract cycle begins in July 2013.

98% of of those receiving Heartland I.V.

Care would recommend this care to others.

A 65-Year Reunion Heartland held a veteran’s pinning ceremony

at an assisted living facility in Virginia. As other

veterans told their stories, one veteran focused his

attention on a man and daughter sitting across

the table. Because he was too hard of hearing

to speak for himself, the man’s story was told by

his daughter. After her presentation, the veteran

across the table asked, “Did you say your dad was

in the Army during WWII and flew ‘the Hump?’”

“Yes,” she said. “He loaded airplanes with

supplies to be flown across the Himalayas so

the Chinese could defend themselves against

Japan.” The man then asked, “What’s your

father’s name?” “Sgt. Ward Wheeler,” she

responded. The man smiled and yelled,

“We served together there. He loaded

for me, and I flew! Ward, look at me.

It’s Sgt. Nunemaker.” Two veterans were united

by chance. “If it hadn’t been for Heartland and ‘We

Honor Veterans,’” the daughter said, “they would

have never known.”


HCR ManorCare’s Arden Courts memory care communities were researched, designed and developed specifically for those suffering with memory loss from Alzheimer’s disease or other types of dementias. Memory care is all we do at Arden Courts, and programs have been developed to maximize each resident’s remaining skills and abilities to enhance his or her sense of independence and self-esteem. We have found that when structuring the day for someone living with dementia, programs must be based on that individual’s interests, hobbies and habits, which have been formed over a lifetime. One size programming does not fit all, and we have found that effective programs rely on activities that are created and adjusted to individual needs and functional ability.

While programs are tailored to the individual needs of residents, they fall into a few basic categories. Daily life programming at Arden Courts distinguishes abilities, capabilities and preferences and provides four types of programs.

Individual Pursuits benefit residents who do not like or are cognitively unable to participate in structured group programs. Individual pursuits are arranged by programming staff and staged so that an individual is prompted to participate in leisurely outdoor strolls, pruning plants, sanding wood or working on a word game.

Engagement Therapy Treatment is an exclusive Arden Courts program that provides an opportunity for residents with similar functional and cognitive abilities to socialize and share with others in a group setting. Sharing involves subjects such as art appreciation, poetry, food creations and craft projects. It is a way to enjoy times together sharing past memories and discussions of the present in a small, structured group setting that nurtures communication and friendships.

Lifestyle Programming is similar to engagement therapy treatment in that it involves interaction with others. Activities encourage interaction in an open community setting based on the residents’ interests, hobbies and routines, and to the extent that is reasonable and meaningful to them. One result of the programming is that it stimulates friendships among participants.

Arden Courts was the first national company to use the Namaste Care Program. Namaste is a Hindu term meaning “honoring the spirit within.” It is used most effectively with individuals with advanced dementia when verbal communication is limited due to the disease process, and touch becomes the meaningful language to demonstrate care, concern and love. Namaste Care nurtures and stimulates the senses using assistance such as scents of lavender, soft music, nature scenes, warmth, touch and hydration. It results in a state of peacefulness that cannot be reached by many late-stage dementia residents through other programs.

Memory CareWe know. We understand. We can help

64% of the families

selecting Arden Courts

have toured three to

five communities prior

to making their decision,

and 86% toured two or

more communities.


With nearly 20 years of caring exclusively for individuals presenting all levels of dementia, our Arden Courts communities know the emotional commitment and critical decisions that families must manage as dementia progresses and greater loss occurs. Making an informed care decision includes understanding changes, safety risks and the right time to choose a protected and safe environment. Waiting until a crisis such as leaving on a stove, wandering away from home, a car accident, setting the microwave on too long and an inability to dial 911 can result in heartbreak and misfortune for the individual with memory loss and for family members seeking to allow independence when what’s needed is a protected environment. We partner with our families, individuals presenting in all stages of dementia and professionally trained staff to strive for the goal with our dementia services to provide a safe, supportive and home-like environment that nurtures the individuality of memory-impaired people and gives their families peace of mind.

93% of the families of

residents rated the safety

of our Arden Courts centers

as “Excellent” or “Good.”

94% of the families

of residents rated their

overall satisfaction with

Arden Courts centers as


95% of the families of

residents rated the home-

like environment of our

Arden Courts centers as



The Arden Courts Model Makes a differenceBetty was admitted to Arden Courts of Fair Oaks in Fairfax, Virginia in October 2012 from another facility that cares for those with dementia. When admitted to our memory care community, Betty was taking the antipsychotic medications Ativan as needed, Depakote and Seroquel. Staff at Arden Courts Fair Oaks was told she was on these medications because she had extreme behavioral issues, including hitting, and because it was the only way the facility could get her to cooperate with her care.

When Betty came to Arden Courts, a conference was held with family. Staff explained that it would be important for Betty to not change any medications for at least the first 30 days to ease her adjustment into the new environment. But the family was also told that after this period, they would be working to reduce use of these medications.

On these drugs, Betty was like a robot, showing very little emotion and not very talkative. In November, staff decreased her Depakote dosage from three times a day to two. In about two weeks, staff started to see more facial expressions, and Betty began to interact more.

There were moments of agitation during this period, but through appropriate communication and allowing Betty to have as much control as possible within safety limits, staff was able to work her through it. In December, Betty’s Depakote dosage was reduced to once a day. Facial expressions increased further, she engaged in additional appropriate conversation, and more of her personality came forth. In January, her Seroquel was discontinued. Ativan had been prescribed to use as needed in extreme situations. Since everything went well with Betty, it has not been used.

Arden Courts prides itself on the training it provides staff in all aspects of the dementia process. That and the Arden Courts environment undoubtedly made a difference in Betty’s progress within our memory care community and the elimination or reduction of incapacitating medications. Staff was able to offer her a measure of control in a structured and safe environment. They met Betty where she was in her disease process, and the care and compassion that the staff showed her made a huge difference. Taking time with the family at admission, learning who Betty was prior to her dementia and understanding where she was now helped staff to better interact with Betty and meet her needs.

97% of the families

of Arden Courts

residents rated the

respect shown them

by staff as “Excellent”

or “Good.”

95% of the families

of residents rated

the caring of our

Arden Courts staff

as “Excellent” or

“Good.”

94% of the families

of Arden Courts

residents would tell

others that our services

rate “Excellent” or

“Good.”


What family members are saying:

“My mother recently passed in the amazing loving care of the staff at Arden Courts. Every single staff member has been kind and supporting to not only Mom but also my two brothers and me. I live in California, and my Arden Courts Guardian Angel was such a comfort; she always made me feel safe. I asked a staff person once if the staff knew how really incredible they were, and she said, ’We are ALL really well trained.’ I thought that was such a beautiful answer – something that seamless does not just ‘happen.’ People are working very hard to do the right thing and all go in the same direction at Arden Courts. It shows and is appreciated. Mom and I made it to one magical Namaste Care session. I truly believe that it was in the loving ministrations that afternoon that Mom found her path. It was lovely to see the reaction of the other residents as well as the staff, and it clearly eased me a great deal as well. What a wonderful new offering.” Arden Courts community in Pennsylvania

“My family and I would like to extend to all of you our profound thanks for having cared for our mother for the past seven years. Your kindness, compasssion and excellent care helped us to know and trust that she was in very good hands. You kept her safe, you kept her clean, you made her smile and laugh, and she was always well-groomed. You treated her with affection which included lots of hugs. To all of the caregivers, we commend your patience and the way that you deal with all of the residents who constantly live in a place of wonder – wondering who they are, where they are, who you are, where they’re supposed to be. You seem to be able to be in whatever reality each resident is in at any given time without getting flustered. It takes very special individuals to be able to stay centered among all the confusion. Arden Courts offers all those things and more, and you come highly recommended by all of us.”Arden Courts community in New Jersey

“Since Mom’s memorial service on Monday, I have been reflecting on the past nearly four years when I first received the phone call from her panicking because she couldn’t figure out her bills. After months of trying so hard to keep her in the home she so loved, it became evident that the situation was becoming dangerous, and I feared for her safety. It was an especially difficult decision for me, because she had been pregnant with me at the time when she and my dad were building the house. It had been her home for 60 years. Thankfully, a friend and co-worker whose mother was living at an Arden Courts in New Jersey sent me in your direction. I will be eternally grateful to her because I couldn’t have found a better place for Mom to live her remaining years. Mom grew to love the staff that treated her so well. She never tired of telling me, “They say be good to your children because they are the ones who are going to pick your nursing home, so I must have been WONDERFUL!” That says a lot about your facility and staff.”Arden Courts community in Pennsylvania


Quality Care from a Quality WorkforceHCR ManorCare has a long-standing tradition of growing talent, developing skills and generally preparing people for their roles as providers of quality health care. Our Continuous Employee Communication initiative is a focused effort to connect with our employees in a meaningful and productive way on a wide variety of issues. It is our way to help ensure that every employee is informed and is part of location initiatives and activities. Small group meetings every other month provide a discussion forum on patient care, personnel policies and practice, location accomplishments and sharing ideas on addressing challenges. A monthly newsletter distributed to all employees, We Are HCR ManorCare, is celebrating its fifth anniversary of sharing stories of frontline employees using their time, talent, hearts and minds to help and inspire others.

Our Circle of Care program comprises training and exercises designed to strengthen our caring philosophy by focusing on how we should treat one another. The program teaches employees how to listen, to say the right thing at the right time, to understand and effectively use body language, to understand what motivates the actions of families, and to help ensure patients and their families are satisfied guests.

Ongoing learning and development help ensure that our employees are continually provided the tools they need to stay at the top of their profession. Our online HCR ManorCare University enables employees to enhance skills through the convenience of their computers.


“ Administration is polite and approachable; they listen to employees.”

“ We care about one another and are able to have fun at the workplace.”

“ Excellent leadership + teamwork. HCR ManorCare truly cares for the patients. The quality of services is superb. I truly love my job because of the constant support I receive.”

“ Both leadership and direct supervisor are receptive to new ideas and initiatives. Direct supervisor and leadership make me feel valued, heard, validated.”

“ The caring culture and in-services on customer service are great. The ‘do what is best for the patient/family’ approach is so important to me.”

“ The general staff works wonderfully together, and we are like a loving family, looking out for one another and caring for our patients with the same love.”

“ I feel supported and valued by the leadership team. I truly feel they do their best to ensure hearing our concerns and questions and that they are available for input.”

“ The administrative staff here is excellent. There is good communication, with regular staff meetings to share information. This seems more as a ‘family’ rather than merely a place to work.”

HCR ManorCare’s supportive

workplace has led to comments

such as these on surveys distributed

to employees on an 18-month cycle:

25Experience Makes a DifferenceExperience Makes a Difference

All of this leads to long-tenured and seasoned employees with a proven track record of success.

n More than 7,000 employees have 10 years or more of service.

n Nearly 2,000 have 20 years or more of service.

n About 500 have 30 years or more of service.

n Over 30 remarkably have 40 years or more of service.

Having a caring, positive work environment leads to quality care for our patients and residents. In 2012, we received nearly 1,800 complimentary calls on HCR ManorCare’s Care Line. Among those compliments are the following:

“ We want to thank and compliment the staff for their expertise, professionalism and kindness that has helped my father live well and safely. A special thank you goes to the therapy team. These outstanding professionals helped strengthen my father through their caring therapy, but also taught him and his family skills so that upon his return to home, he could continue with his learned safety skills.”

“ Last Sunday, we celebrated our 59th wedding anniversary. The staff did a beautiful job and put on a wonderful celebration. The flowers were very nice, and the appetizers were great. We had a good time.”

“ I was transferred to ManorCare from a local hospital. The facility is so much better than the hospital. I don’t have to wait for my medication, my pain is controlled, and the staff is wonderful. The food is 100% better, too. My nurse is the best. I appreciate everything they do for me.”

26 Experience Makes a DifferenceExperience Makes a Difference

Tihesa’s life seemed picture perfect – a rewarding career in marketing, a husband with a thriving home-based

business and a beautiful baby girl that they had just welcomed into their lives. Two weeks after the baby was

born, Tihesa’s husband came down with a 104-degree fever. Suddenly, his condition worsened. He was in a

diabetic coma, suffering from kidney failure, and he was placed on dialysis. With Tihesa on maternity leave and

her husband unable to work, money quickly became very tight, and the couple was forced to rely on family and

friends. HCR ManorCare Human Resources helped her apply to the Hug Fund, and the money helped her get

through a very tough time as her husband recovered.

Just as things were beginning to return to normal, Tihesa received a devastating phone call while housesitting

for her aunt. Tihesa’s house was engulfed in flames. By the time she returned home, everything had been lost.

Family pictures, her baby’s toys, her husband’s home office, everything. Tihesa’s insurance company stalled on a

settlement, and the family once again found itself at financial risk. Once again, the Hug Fund came through, and

Tihesa and her family were able to recover. They recently closed on a new home.

HCR ManorCare Gives is our company’s commitment to our patients, employees and communities demonstrated through our many philanthropic programs. Here are highlights of two of our most supportive programs:

The Hug Fund, a non-profit charity, is a partnership of HCR ManorCare employees helping their fellow employees who have experienced a catastrophic event causing financial hardship. Whether it’s an employee whose home has been destroyed by fire, who has been diagnosed with a terminal illness, whose child has died or who lost his or her possessions to a tornado, the Hug Fund is there to help. The fund provides financial assistance to employees who are unable to meet their urgent need.

Many Hug Fund grant applicants are experiencing catastrophic financial distress as a result of a medical crisis. Time off from work, decreased income, and caregiver and medical expenses can cause utility disconnection and even homelessness. These employees are in need of a financial bridge to regain financial stability. The Hug Fund can enable these families to get through a very difficult time and by providing that bridge. Through the financial support of HCR ManorCare employees, the Hug Fund is able to offer hope and peace of mind for HCR ManorCare employees across the nation.


The Heartland Hospice Memorial Fund, a non-profit charity, believes that people who are at the end of their lives should be able to focus on enjoying time with their family and friends, cherishing their last days and making lasting memories. But financial stressors due to a terminal diagnosis often complicate the end-of-life journey, leaving little time for families and friends to focus on this important time with the patient. The fund can relieve the financial pressures experienced by patients and their families coping with terminal illness and its aftermath by providing financial assistance with household expenses, last wishes and funeral expenses, thereby removing the burdens and stressors associated with financial distress directly related to illness.

Many grants from the Heartland Hospice Memorial Fund are awarded to fulfill a patient’s dying wishes to bring faraway family members to visit, to purchase one-way tickets for the patient to “go home” or spend one last vacation together as a family. Grants are also awarded to assist caregivers as they transition to household financial challenges after the patient’s death. But the majority of grant awards are to simply help patients and their families stay together in the comfort of their homes. The Heartland Hospice Memorial Fund also provides community education and bereavement resources for those suffering the loss of a loved one.

Miles is a 16-year-old hospice patient who suffers from Duchene muscular dystrophy and relies on a wheelchair. His

room was filled with pictures, paper cutouts and models of airplanes. On one visit, the hospice social worker learned

that Miles wanted to attend an air show that was coming to a nearby town. Miles was excited about the prospect of

seeing the planes and pilots perform. But his wheelchair needed expensive alterations that his family could not afford.

In addition, the patient’s family lacked the extra money to cover the cost of the trip.

The Heartland Hospice Memorial Fund provided funds for the wheelchair enhancements and travel expenses in order

for Miles to attend the air show. Then, the hospice staff contacted the USAF Thunderbirds, and the magic began.

Miles and his family received VIP passes to the show and access to VIP areas where spectators were usually not

allowed. They met with several high-ranking officers. Miles also met the A-10 Warthog pilots, the Air Force Academy

Wings of Blue skydiving team and all of the Thunderbird pilots. He was able to get many pictures and autographs. He

was given a hat and T-shirt from an air wing unit called the Red Devils. One of the pilots, a former F-16 and current

A-10 pilot, explained to Miles that when pilots receive enough hours to fly a plane, they receive a coin and their call

sign. He then gave Miles his own coin and gave him the call sign “Miles High.” Miles was smiling from ear to ear as he

told the hospice staff that the day at the air show was the best day of his life.


® 2013 HCR Healthcare, LLCHCRMC-0058E

HCR ManorCare 333 N. Summit Street, Toledo, Ohio 43604

419-252-5500 • hcr-manorcare.com

2013 quality report

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